General Guideline Principles for Biceps Tendinosis (or Tendinitis) and Tears/Ruptures for workers compensation patients

The guidelines set forth by the New York State Workers Compensation Board aim to aid physicians, podiatrists, and healthcare professionals in delivering proper treatment for Biceps Tendinosis (or Tendinitis) and Tears/Ruptures.

These guidelines serve as a valuable resource for healthcare professionals when determining the most suitable level of care for patients dealing with Biceps Tendinosis

It’s important to emphasize that these guidelines are not meant to replace the need for clinical judgment or professional expertise. The final decision regarding patient care should be a collaborative one made by the patient and their healthcare provider.


Biceps Tendinosis (or Tendinitis) and Tears/Ruptures

Biceps tendinosis (or tendinitis) is a genuine muscular strain that affects the muscle-tendon junction of the biceps brachii (refer to the Shoulder Injury MTG for bicipital tendinitis and shoulder ruptures). This condition often arises when excessive force is applied, particularly if one is unaccustomed to such exertion.

The primary symptom is non-radiating pain at the muscle-tendon junction, usually without paraesthesias. Pain and mild weakness are commonly reported, making them among the most prevalent complaints associated with this condition.

While tendonitis and rupture are typically viewed as distinct conditions, there is considerable overlap across mild, moderate, and severe ruptures. The severity of the rupture directly correlates with the likelihood of requiring surgery to restore optimal function, particularly in individuals of working age.


Diagnostic Criteria of Biceps Tendinosis (or Tendinitis) and Tears/Ruptures

The diagnosis of biceps tendinosis relies on a combination of a typical triggering event, often involving high-force exertion like a maximal lift or unaccustomed stereotypical high-force use, and the characteristic localized elbow pain at the affected myotendinous junctions where they insert in the distal biceps tendon in the lower part of the upper arm.

Focal soreness is evident over the impacted and disturbed connections, and the presence of ecchymosis is a possibility, typically inversely correlated with the severity of junctional rupture or tear. In more severe biceps ruptures, myotendinous junctions can be torn to the extent that one or both of the biceps brachii are completely torn.

These ruptures are strongly associated with weakness in elbow flexion. A physical examination may reveal palpable anomalies, such as a biceps that feels “ropey” in the insertion location, often accompanied by the presence of a hematoma.


Diagnostic Studies

X-rays as Diagnostic Studies for Biceps Tendinosis For patients with biceps tendinosis and tears, X-rays can be considered for evaluation, but more commonly, MRI and ultrasound are employed.

Reason for Recommendation: MRI or ultrasound is typically the preferred choice over X-rays, making them secondary in the diagnostic process. X-rays, however, are particularly recommended in cases of acute trauma to rule out fractures. Being non-invasive, cost-effective, and with rare serious side effects, X-rays are advised for this purpose.

MRI for Biceps Tendinosis or Ruptures For cases involving ruptures or tendinosis of the biceps, MRI is recommended.

Indications: Especially for patients where the need for surgery is uncertain, particularly those with mild to severe biceps tendinosis or ruptures. Complete rupture patients often may not require MRIs, as they frequently don’t alter the necessity for surgery.

Since the test doesn’t significantly impact the treatment plan or the positive prognosis, patients with small tears usually do not need MRIs.

Ultrasound of Biceps Tendinosis Ultrasound is recommended for assessing and diagnosing ruptured or tendinosis biceps.

Indications: Patients with moderate to severe biceps tendinosis or ruptures, especially when the need for surgery is uncertain. Complete rupture patients typically may not need diagnostic ultrasonography, as it usually doesn’t alter the necessity for surgery.

Patients with minor tears usually do not require ultrasound since the procedure doesn’t alter the course of treatment or the likelihood of a positive outcome. Generally, ultrasound should not be used in addition to MRI, as it usually doesn’t provide additional useful information.

Rationale for Recommendation: Diagnostic ultrasound is likely the second most popular imaging test for determining the severity of biceps tendonitis or rupture, following MRI.

In patients with fairly severe tears, when the extent of rupture may influence the decision for surgery, ultrasound can be helpful in assessing the necessity for surgery.


Medications of Biceps Tendinosis

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are recommended as the initial treatment for most patients. Acetaminophen (or the analog paracetamol) can be a viable alternative for patients not suitable for NSAIDs, although research generally suggests it is only slightly less effective than NSAIDs.

There is evidence supporting the safety and efficacy of NSAIDs in managing pain, making them a preferable option to opioids like tramadol.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment NSAIDs are recommended for treating Biceps Tendinosis and Tears. It is advisable to start with over-the-counter (OTC) medications to assess their effectiveness.

Frequency/Duration – Many patients may find it reasonable to use NSAIDs as needed.

Indications for Discontinuation – Discontinuation may be warranted if elbow pain eases, if the treatment proves ineffective, or if side effects emerge.

NSAIDs for Patients at High Risk of Gastrointestinal Bleeding NSAIDs are recommended for individuals at high risk of gastrointestinal bleeding, often used in combination with cytoprotective drugs like misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors.

Indications – Cytoprotective drugs should be considered for patients with a high-risk factor profile who also need NSAIDs, especially for extended treatment. Those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers are considered at risk.

Frequency/Dose/Duration – H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are recommended, following dosage recommendations from the manufacturer. Effectiveness in preventing gastrointestinal bleeding is generally accepted to be comparable.

Indications for Discontinuation – Discontinuation may be necessary in the case of NSAID intolerance, the emergence of negative side effects, or if the medication is stopped.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects For individuals at risk of cardiovascular adverse effects, acetaminophen or aspirin is generally considered the safest medication as a first-line therapy.

If needed, non-selective NSAIDs are preferred over COX-2-specific medications. To minimize the risk of NSAIDs counteracting the protective effects of low-dose aspirin in those using it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

Acetaminophen for Elbow Pain Relief Acetaminophen is recommended for alleviating elbow discomfort, particularly in patients with contraindications for NSAIDs.

Indications – Suitable for all patients experiencing acute, subacute, chronic, or post-operative elbow pain.

Frequency/Dose/Duration – Follow the manufacturer’s recommendations; can be used as needed. However, caution should be exercised, as evidence of liver toxicity exists when consumption exceeds four gm/day.

Indications for Discontinuation – Discontinue when pain subsides, side effects emerge, or intolerance occurs.

Opioids for Specific Cases of Biceps Tendinosis Opioids are recommended for a select group of individuals experiencing moderately severe to severe biceps tendinosis or ruptures, particularly when the pain disrupts sleep. This option is also suitable for patients recovering from surgery.

Indications – Reserved for patients with significant pain from moderate to severe biceps tendinosis or ruptures, unresponsive to conventional treatments like acetaminophen and NSAIDs, or those with NSAID contraindications. Patients in postoperative recovery are also eligible. Caution is advised, and the minimum effective dose should be administered, especially considering the typically short recovery time for elbow sprains.

Frequency/Dose – Administered as needed, with a focus on nighttime usage, which is commonly preferred by many patients. A planned dose may be necessary for the first few days following surgery. Nonoperative patients are generally encouraged to discontinue opioid use within seven days.

Indications for Discontinuation – Discontinue in the presence of undesirable effects, deviation from prescribed consumption guidelines, or sufficient pain relief that negates the need for opioids.

Rationale for Recommendation – While postoperative patients may require brief opioid treatment for a few days, nonoperative individuals typically don’t. Opioids may be necessary for specific cases of moderately severe to severe biceps tendinosis or when NSAIDs are insufficiently effective. The recommendation emphasizes short-term and careful usage in a targeted patient population.


Treatments Biceps Tendinosis

Initial Care Evidence for Opioid Use: Patients with severe or complete ruptures should be referred to a surgeon to assess the need for surgical repair. Treatment for other patients should involve activity restrictions and pain management methods typically centered around NSAIDs.

Monitoring Progress: Regular evaluations every seven to fourteen days are recommended to assess patient progress. If there is a lack of improvement, diagnostic testing (refer to the above) and potential referral for surgical repair should be considered.

Rehabilitation: Devices / Therapy: Rehabilitation, particularly supervised formal therapy after a work-related injury, should focus on restoring the functional abilities required for the patient’s daily and work responsibilities, aiming to return them to their pre-injury status as much as practically possible.

Active therapy involves the patient’s internal effort to complete specific activities or tasks, while passive therapy relies on modalities administered by a therapist. Passive therapies are often used to expedite active therapy programs and achieve concurrent functional gains. Prioritizing active initiatives over passive interventions is recommended. To maintain improvement levels, patients should continue both active and passive therapies at home as an extension of the therapeutic process.

The integration of assistive technology into the treatment strategy can be considered to promote functional improvements.

Exercise for Biceps Tendinosis: Patients are often advised to perform gentle range-of-motion exercises multiple times a day within a pain-free range to preserve a normal range of motion during recovery. Excessive stretching is to be avoided during the acute healing phase, which should also be free of intense or heavy forceful use. Interventions are available to address changes in Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) performance.

Therapy (Active) of Biceps Tendinosis

Exercises for Biceps Tendinosis, Ruptures, or Post-Operative Patients

Exercises for Biceps Tendinosis, Ruptures, or Post-Operative Patients are recommended as part of the treatment for biceps tendinosis, ruptures, and post-operative patients, emphasizing strengthening exercises.

Indications – All patients with biceps tendinosis are eligible.

Frequency/Dose/Duration – The total number of visits may vary, ranging from as low as two to three for individuals with minor functional deficits to as high as 12 to 15 for those with more severe deficits, depending on the verification of continued objective functional progress.

If there is evidence of functional improvement toward specific goals (e.g., enhanced grip strength, key pinch strength, range of motion, or improved capacity to perform work activities), more than 12 to 15 visits may be necessary to address persistent functional impairments.

As part of the rehabilitation strategy, a home exercise regimen should be developed and implemented alongside therapy.

Duration – Varies significantly depending on severity, pre-injury conditioning, and employment requirements.


Devices of Biceps Tendinosis

Slings and Splints for Biceps Tendinosis, Ruptures, and Post-Operative Patients

Slings and Splints for Biceps Tendinosis, Ruptures, and Post-Operative Patients are recommended as part of the treatment for post-operative patients, ruptures, and biceps tendinosis.

Indications – Particularly beneficial for patients moderately to severely impacted, especially during the initial week. Post-operative patients are often prescribed posterior splints to wear for approximately two weeks (with a range of one to six weeks).

Duration – Ideally, the usage should be gradually reduced to fewer than seven to 10 days. For non-operative patients wearing a sling or splint, it is advisable to perform range-of-motion exercises for the elbow and shoulder multiple times daily to prevent postoperative issues arising from restricted ranges of motion.


Surgery of Biceps Tendinosis

A rupture of the distal biceps tendon may occur in cases of severe biceps tendinosis. These recommendations specifically address a ruptured distal biceps tendon, not a ruptured (proximal) bicipital tendon, which occurs in the shoulder’s bicipital groove and often does not necessitate surgery.

Nonoperative treatment is a viable option for distal biceps tendon ruptures, and some experts emphasize that certain patients, especially older individuals or those with modest job demands, may still prefer non-operative approaches.

However, distal biceps ruptures typically result from supramaximal force and, in most working patients, necessitate surgical repair. Surgical techniques may involve endoscopic, double-incision, or single-incision procedures.


Surgical Repair for Distal Biceps Ruptures

Surgical repair is recommended for ruptured distal biceps tendons.

Indications – Surgery is indicated for complete, massive ruptures or in some individuals with moderately severe biceps tendinosis who do not show satisfactory improvement with non-operative treatment.

Demonstrated adherence. Patients with significant physical job demands but only mild tears are also considered candidates for surgery to restore enough function to resume their duties.


What our office can do if you have Biceps Tendinosis (or Tendinitis) and Tears/Ruptures

We have the expertise to assist you with your workers’ compensation injuries. We recognize the challenges you are facing and are committed to addressing your medical needs while adhering to the guidelines established by the New York State Workers Compensation Board.

We comprehend the significance of your workers’ compensation cases and are here to guide you through the complexities of interactions with the workers’ compensation insurance company and your employer.

We acknowledge that this is a demanding period for you and your family. If you wish to schedule an appointment, please reach out to us, and we will make every effort to ensure the process is as smooth and stress-free for you as possible.

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